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Derner B, Derner R. Small Joint Arthroscopy of the Foot. Clin Podiatr Med Surg 2023; 40:445-457. [PMID: 37236682 DOI: 10.1016/j.cpm.2023.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Recently, there have been new advances in the arthroscopic approach to small joints of the foot. This is directly related to the improvement of surgical equipment, new techniques, and publications. These improvements led to broadening indications as well as minimizing complications. Several articles recently presented the uses of arthroscopic surgery in the small joints of the foot; however, the use is still relatively limited. Arthroscopic evaluation of the small joints of the foot includes the first metatarsophalangeal, lesser metatarsophalangeal, tarsometatarsal, talonavicular, and calcaneocuboid joints as well as the interphalangeal joint to the great toe and lesser toes.
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Affiliation(s)
- Brian Derner
- Kaiser San Leandro Medical Center, 2500 Merced Street, Suite 403, San Leandro, CA 94577, USA.
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Park JV, Finney FT, Singer NV, Saunders NE, Walley KC, Holmes JR, Walton DM, Talusan PG. Proximal Plantar Plate of Lesser Toe Metatarsophalangeal Joint Vascular Supply. Foot Ankle Int 2023; 44:75-80. [PMID: 36539967 PMCID: PMC9918344 DOI: 10.1177/10711007221140043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND The plantar plate is a major stabilizing structure of the metatarsophalangeal (MTP) joint with instability frequently occurring after a tear or attenuation of this structure. Commonly, a McGlamry elevator is used to strip the plantar plate from the plantar surface of the metatarsal to improve exposure of the MTP joint. The anatomy of the proximal plantar plate and vascular consequence of stripping the plantar plate from the metatarsal is not yet well understood. The purpose of this study is to describe the proximal attachment of the plantar plate anatomically and quantify the relative contribution of blood supply to the proximal plantar plate from both the metatarsal and the plantar fascia. METHODS For anatomic evaluation, 6 lower extremity cadaver specimens without any gross evidence of foot and ankle deformity were utilized. For imaging analysis, 16 fresh frozen human adult cadaveric lower extremity specimens were used for this study, resulting in 35 MTP joints without deformity and 11 lesser MTP joints with cockup and/or crossover deformities. The specimens were prepared as described previously by Finney et al.5. RESULTS From gross anatomic dissection, the plantar plate origin consists of a stout fibrous pedicle distinct from the surrounding synovial-type tissue that firmly anchors the plantar plate to the metatarsal. Based on nano-computed tomographic imaging, an average of 63.5% of the vascular supply to the proximal portion of the plantar plate entered from the metatarsal pedicle. The remaining 36.5% of the vascular supply entered from the plantar fascia. CONCLUSION The proximal attachment of the plantar plate includes a stout fibrous pedicle anchoring the proximal portion of the plantar plate to the notch between the medial and lateral plantar condyles of the metatarsal head. The vascular supply of the proximal plantar plate is supplied from both the metatarsal pedicle and plantar fascia. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Jiwon V. Park
- University of Michigan Medical School, Ann Arbor, MI
| | - Fred T. Finney
- Department of Orthopaedic Surgery, Michigan Medicine, Ann Arbor, MI
| | | | - Noah E. Saunders
- The University of Toledo College of Medicine and Life Sciences, Toledo, OH
| | | | - James R. Holmes
- Department of Orthopaedic Surgery, Michigan Medicine, Ann Arbor, MI
| | - David M. Walton
- Department of Orthopaedic Surgery, Michigan Medicine, Ann Arbor, MI
| | - Paul G. Talusan
- Department of Orthopaedic Surgery, Michigan Medicine, Ann Arbor, MI
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Singer NV, Saunders NE, Holmes JR, Walton DM, Finney FT, Jepsen KJ, Talusan PG. Presence of Neovascularization in Torn Plantar Plates of the Lesser Metatarsophalangeal Joints. Foot Ankle Int 2021; 42:944-951. [PMID: 33563043 PMCID: PMC8286279 DOI: 10.1177/1071100721990038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Recent surgical techniques have focused on anatomic repair of lesser toe metatarsophalangeal (MTP) plantar plate tears, yet it remains unknown whether the plantar plate has the biological capacity to heal these repairs. Therefore, a better understanding of the plantar plate vasculature in response to injury may provide further insight into the potential for healing after anatomic plantar plate repair. Recently, a study demonstrated that the microvasculature of the normal plantar plate is densest at the proximal and distal attachments. The purpose of this study was to compare the intact plantar plate microvasculature network to the microvasculature network of plantar plates in the presence of toe deformity using similar perfusion and nano-computed tomographic (CT) imaging methods. METHODS Seven fresh-frozen human cadaveric lower extremities with lesser toe deformities including hammertoe or crossover toe were perfused using a barium solution. The soft tissues of each foot were counterstained with phosphomolybdic acid (PMA). Then using nano-CT imaging, the second through fourth toe metatarsophalangeal joints of 7 feet were imaged. These images were then reconstructed, plantar plate tears were identified, and 11 toes remained. The plantar plate microvasculature for these 11 toes was analyzed, and calculation of vascular density along the plantar plate was performed. Using analysis of variance (ANOVA), this experimental group was compared to a control group of 35 toes from cadaveric feet without deformity and the vascular density compared between quartiles of plantar plate length proximal to distal. A power analysis was performed, determining that 11 experimental toes and 35 control toes would be adequate to provide 80% power with an alpha of 0.05. RESULTS Significantly greater vascular density (vascular volume/tissue volume) was found along the entire length of the plantar plate for the torn plantar plates compared to intact plantar plates (ANOVA, P < .001). For the first quartile of length (proximal to distal), the vascular density for the torn plantar plates was 0.365 (SD 0.058) compared to 0.281 (SD 0.036) for intact plantar plates; in the second quartile it was 0.300 (SD 0.044) vs 0.175 (SD 0.025); third quartile it was 0.326 (SD 0.051) vs 0.117 (SD 0.015); and fourth (most distal) quartile was 0.600 (SD 0.183) vs 0.319 (SD 0.082). CONCLUSION Torn plantar plates showed increased vascular density throughout the length of the plantar plate with an increase in density most notable in the region at or just proximal to the attachment to the proximal phalanx. Our analysis revealed that torn plantar plates exhibit neovascularization around the site of a plantar plate tear that does not exist in normal plantar plates. CLINICAL RELEVANCE The clinical significance of the increased vascularity of torn plantar plates is unknown at this time. However, the increase in vasculature may suggest that the plantar plate is a structure that is attempting to heal.
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Affiliation(s)
- Natalie V. Singer
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Noah E. Saunders
- The University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
| | - James R. Holmes
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - David M. Walton
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA
| | | | - Karl J. Jepsen
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Paul G. Talusan
- Department of Orthopaedic Surgery, University of Michigan Health System, 2098 South Main St., Ann Arbor, MI 48103, USA
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State of the Art in Lesser Metatarsophalangeal Instability. Foot Ankle Clin 2019; 24:627-640. [PMID: 31653367 DOI: 10.1016/j.fcl.2019.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Advancements in lesser metatarsophalangeal (MTP) instability have involved the use of minimally invasive surgery techniques, synthetic augmentation of existing transfers, and use of arthroscopy for both diagnosing and addressing MTP disorder. Advances in imaging modalities, particularly MRI, have aided in diagnosing subtle instability. Clinical outcomes seem to be similar to traditional approaches as the indications and applicability continue to evolve.
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Finney FT, McPheters A, Singer NV, Scott JC, Jepsen KJ, Holmes JR, Talusan PG. Microvasculature of the Plantar Plate Using Nano-Computed Tomography. Foot Ankle Int 2019; 40:457-464. [PMID: 30565497 PMCID: PMC6443423 DOI: 10.1177/1071100718816292] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND: Lesser toe plantar plate attenuation or disruption is being increasingly implicated in a variety of common clinical conditions. A multitude of surgical techniques and devices have been recently developed to facilitate surgical repair of the plantar plate. However, the microvascular anatomy, and therefore the healing potential in large part, has not been defined. We investigated the microvasculature of the plantar plate by employing a novel technique involving microvascular perfusion and nano-computed tomography (nano-CT) imaging. METHODS: Twelve human adult cadaveric lower extremities were amputated distal to the knee. The anterior and posterior tibial arteries were perfused with a barium solution. The soft tissues of each foot were then counterstained with phosphomolybdic acid (PMA). The second through fourth toe metatarsophalangeal (MTP) joints of 12 feet were imaged with nano-CT at 14-micron resolution. Images were then reconstructed for analysis of the plantar plate microvasculature and calculation of the vascular density along the length of the plantar plate. RESULTS: A microvascular network extends from the surrounding soft tissues at the attachments of the plantar plate on both the metatarsal and proximal phalanx. The midsubstance of the plantar plate appears to be relatively hypovascular. Analysis of the vascular density along the length of the plantar plate demonstrated a consistent trend with increased vascular density at approximately the proximal 29% and distal 22% of the plantar plate. CONCLUSION: There is a vascular network extending from the surrounding soft tissues into the proximal and distal attachments of the plantar plate. CLINICAL RELEVANCE: The hypovascular midportion of the plantar plate may play an important role in the underlying pathoanatomy and pathophysiology of this area. These findings may have significant clinical implications for the reparative potential of this region and the surgical procedures currently described to accomplish anatomic plantar plate repair.
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Affiliation(s)
- Fred T. Finney
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Aaron McPheters
- University of Louisville School of Medicine, Louisville, KY, USA
| | - Natalie V. Singer
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Jaron C. Scott
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Karl J. Jepsen
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - James R. Holmes
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Paul G. Talusan
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA
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Abstract
Knowledge and command of anatomy is paramount to effectively treating disorders of the lesser metatarsophalangeal (MTP) joints. The osseous structures consist of the proximal phalanx of the toe and the metatarsal head. The soft tissues on the dorsum of the MTP joint include the joint capsule and the tendons of extensor digitorum longus and extensor digitorum brevis. The proper and accessory collateral ligaments form the medial and lateral walls and contribute to stability in the coronal and sagittal planes. The plantar plate forms the plantar border of the MTP joint and stabilizes the MTP joint against hyperextension and dorsal translation.
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Affiliation(s)
- Fred T Finney
- Department of Orthopaedic Surgery, University of Michigan, 2098 South Main Street, Ann Arbor, MI 48103, USA
| | - Ezequiel Cata
- Department of Orthopaedic Surgery, Sanatorio Allende, Independencia 757, Cordoba Capital, Córdoba, Argentina
| | - James R Holmes
- Department of Orthopaedic Surgery, University of Michigan, 2098 South Main Street, Ann Arbor, MI 48103, USA
| | - Paul G Talusan
- Department of Orthopaedic Surgery, University of Michigan, 2098 South Main Street, Ann Arbor, MI 48103, USA.
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Reeves CL, Shane AM, Payne T, Cavins Z. Small Joint Arthroscopy in the Foot. Clin Podiatr Med Surg 2016; 33:565-80. [PMID: 27599441 DOI: 10.1016/j.cpm.2016.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Arthroscopy has advanced in the foot and ankle realm, leading to new innovative techniques designed toward treatment of small joint abnormality. A range of abnormalities that are currently widespread for arthroscopic treatment in larger joints continues to be translated to congruent modalities in the small joints. Small joint arthroscopy offers relief from foot ailments with a noninvasive element afforded by arthroscopy. Early studies have found comparable results from arthroscopic soft tissue procedures as well as arthrodesis of the small joints when compared with the standard open approach.
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Affiliation(s)
- Christopher L Reeves
- Orlando Foot and Ankle Clinic, 2111 Glenwood Drive, Suite 104, Winter Park, FL 32792, USA; Surgical Residency Program, Department of Podiatric Surgery, Florida Hospital East Orlando, 7727 Lake Underhill Road, Orlando, FL 32828, USA.
| | - Amber M Shane
- Surgical Residency Program, Department of Podiatric Surgery, Florida Hospital East Orlando, 7727 Lake Underhill Road, Orlando, FL 32828, USA; Orlando Foot and Ankle Clinic, 250 North Alafaya Trail, Suite 115, Orlando, FL, USA
| | - Trevor Payne
- Podiatric Medicine and Surgery Resident (PGY3), Residency Training Program, Florida Hospital East Orlando, 7727 Lake Underhill Road, Orlando, FL 32828, USA
| | - Zac Cavins
- Podiatric Medicine and Surgery Resident (PGY1), Residency Training Program, Florida Hospital East Orlando, 7727 Lake Underhill Road, Orlando, FL 32828, USA
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